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Renal Artery Stenting
Dr. Chris Beck • Updated Jan 2, 2024 • 730 hits
Renal artery stenting is a minimally invasive procedure used to treat narrowed or blocked renal arteries, which can lead to hypertension or kidney damage. The procedure involves the insertion of a stent, a small mesh tube, into the renal artery to restore proper blood flow to the kidneys. Guided by imaging techniques such as fluoroscopy, interventional radiologists carefully place the stent to ensure it stays in place and opens up the artery. Renal artery stenting is typically performed in patients with atherosclerotic disease or fibromuscular dysplasia, conditions that cause the renal arteries to narrow. This procedure can help control high blood pressure, improve kidney function, and reduce the risk of kidney failure, offering a safer, less invasive alternative to surgery.
Table of Contents
(1) Pre Renal Artery Stent Procedure Prep
(2) Renl Artery Stent Procedure Steps
(3) Post-Procedure
Pre Renal Artery Stent Procedure Prep
Indications
Renal artery stenosis with:
• Refractory hypertension and/or declining renal function
• Optimal medical therapy
Renal artery dissection
Hemodynamically significant stenoses:
• 70% stenosis on angiography
• Pressure gradient > 20 mmHg
Contraindications
• Uncorrectable coagulopathy
• Long segment renal artery occlusion
• Diffuse small branch stenoses
• Renal artery <4 mm
• Small atrophic kidney - suggests nonfunction
Pre-Procedural Evaluation
H&P - patient selection is critical:
• Age of onset of hypertension
• Detailed evaluation of hypertension treatment and current medications
• Comorbidities
Imaging:
• Renal arterial Doppler: > 180 cm/s, tardus parvus waveform
• CTA/MRA
• Captopril renal scan
• Angiogram: reserved for potential planned intervention
Labs:
• Platelets
• INR
• GFR
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Renl Artery Stent Procedure Steps
Medications
• Hold antihypertensives day of the renal artery stent procedure
• Antibiotic: cefazolin 1 gram IV
• Heparin or bivalirudin
Access
Access
• May depend on operator comfort and angle of renal artery
• Femoral, brachial and radial
Place 6-Fr guide sheath
• IMA
• Renal standard curve, renal double curve
Angiogram and Stenting
Place sheath at level of renal artery but directed away from ostium
Advance crossing catheter and 0.014" crossing wire ~ 2 cm outside of guide catheter
Direct guide catheter toward ostium
Identify origin of vessel and degree of stenosis:
• Preprocedural planning
• Inject CO2 or contrast to delineate origin
Pull 0.014" wire into crossing catheter and then pull crossing catheter into sheath
Carefully cross lesion with 0.014" wire and crossing catheter
Average diameter of renal artery is 5-7 mm
Predilate
• Undersize balloon relative to artery
• Fully expand balloon
• Avoid higher pressure if balloon expanded at lower atmosheres
Balloon-expandable stents
• Width 5-7 mm
• Length 10-20 mm
• Cover entire length of stenosis
• Land proximal segment of stent 1-2 mm in the aorta
• Can use stent balloon to flare ostium by reinflating at higher pressure
Remove balloon - completely deflate or balloon could move stent
Final angiogram
Post-Procedure
Renal Artery Stent Complications
• Renal artery embolization with infarction of renal parenchyma
• Guidewire perforation of renal artery with subcapsular, perirenal or perirenal hematoma
• Rupture of renal artery by balloon or stent
• Misplacement of stent and dislodgement of stent
• Stent restenosis, thrombosis and infection
• Renal artery pseudoaneurysm
• Acute renal failure
• Access site complications
• Major renal artery stent complications < 5%
Post-Procedural Care
• Bed rest depends on sheath size and potential arterial closure device
• Overnight observation with monitoring of blood pressure, urine output, and follow up creatinine level
• Hypotension following stenting common
• Continue IV fluids
• Aspirin 325 mg PO daily
• Most operators will also initiate plavix 75 mg PO for at least 1 month
Follow-Up
• Renal duplex 2 weeks following procedure to establish baseline
• Duplex Q6 months thereafter
Outcomes
• 66% of HTN patients will see improved BP control and/or reduced antihypertensive medication need
• 75% of renal insufficiency patients will see plateau or improvement in GFR
Additional resources:
[1] Prince M, Tafur JD, White CJ. When and How Should We Revascularize Patients With Atherosclerotic Renal Artery Stenosis?. JACC Cardiovasc Interv. 2019;12(6):505‐517. doi:10.1016/j.jcin.2018.10.023
[2] Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014;370(1):13‐22. doi:10.1056/NEJMoa1310753
[3] Judd E, Calhoun DA. Apparent and true resistant hypertension: definition, prevalence and outcomes. J Hum Hypertens. 2014;28(8):463‐468. doi:10.1038/jhh.2013.140
[4] Stathopoulos JA. Modification of the No-Touch Technique during Renal Artery Stenting. Case Rep Vasc Med. 2013;2013:516267. doi:10.1155/2013/516267
[5] Egan BM, Zhao Y, Axon RN, Brzezinski WA, Ferdinand KC. Uncontrolled and apparent treatment resistant hypertension in the United States, 1988 to 2008. Circulation. 2011;124(9):1046‐1058. doi:10.1161/CIRCULATIONAHA.111.030189
[6] Funaki B. Renal ostial angioplasty and stenting. Part 1: the routine procedure. Semin Intervent Radiol. 2009;26(1):74‐81. doi:10.1055/s-0029-1208385
[7] Funaki B. Renal ostial angioplasty and stenting. Part 2: pitfalls and complications. Semin Intervent Radiol. 2009;26(2):151‐158. doi:10.1055/s-0029-1222460
[8] Rocha-Singh K, Jaff MR, Lynne Kelley E; RENAISSANCE Trial Investigators. Renal artery stenting with noninvasive duplex ultrasound follow-up: 3-year results from the RENAISSANCE renal stent trial. Catheter Cardiovasc Interv. 2008;72(6):853‐862. doi:10.1002/ccd.21749
[9] Goldstein JA, Kolluri R, Rocha-Singh K. Technical Considerations for Renal Artery Stenting. Vascular Disease Management. 2006;3(3)
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Cite This Podcast
BackTable, LLC (Producer). (2023, June 14). Ep. 332 – El Futuro de MSK: Embolizaciones Musculoesqueletas [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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